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a- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> i' FOR OFFIC F; f <br /> -; T10 .44; (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is Q� <br /> made in compliancevt�Jo '_aquiyLCOr ance o. 1862 a rules and regulations of the San Joaquin Local Health Dista t <br /> ounty � . <br /> Exact Site Address _ � City/Town <br /> I 1 <br /> Owner's Name Phone �-� ( _7 l[ <br /> 42 <br /> Address t City a ♦ q 3 <br /> Contractor's Na License#340 Business Phone —+ i <br /> Contractor's Address Mgency Phone �i <br /> kd <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1f <br />` TYPE OF WORK (CHECK): NEW WELL 9�- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION %�—PUMP REPAIR❑ <br /> REPLACEMENT❑ 1, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field /rte _ Cesspool/Seepage Pit /Cu-2.. Other <br /> Property Line �_ Private Domestic Well Public Domestic Well �---�_ <br /> INTENDED USE TYPE OF WELL <br /> ,❑ tN TRIAL ❑ CABLE TOOL Dia. of Well Excavation- <br /> 03'—DOMESTIC/PRIVATE <br /> xcavation "V <br /> �DOMESTIC/PRIVATE ❑ DRILLED Dia" of Well Casing [Y a� f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Se 1 <br /> ❑ CATHODIC PROTECTION �OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urface Seal Installed By; C. <br /> PUMP INSTALLATION: Contractor s a C ♦ 4 <br /> Type of Pump H.P._ f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: C1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />{ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> x <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> F ill call for a Grout in ri to grouting and a final inspection. <br /> Signed X Title: s-cz- .� { Date: �C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> pp'cation Accepted By % Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Firmi Inspection <br /> j Inspection'8 Date S�O Inspection By `a'6 ate <br /> Fee Is Due: El ANNUALLY El PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ti BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION t DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> A <br /> OTHER <br /> ' OTHER 1 <br /> ryx <br /> _)%,Y::l q] aq B� DI is �i�Ta <br /> Received by Date !– Receipt No. Permit No. • ce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9 , <br />